Healthcare Provider Details

I. General information

NPI: 1801964978
Provider Name (Legal Business Name): JACKALYN LEE MITCHELL RN, OGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 COLLEGE ST
JACKSONVILLE NC
28540-5311
US

IV. Provider business mailing address

612 COLLEGE ST
JACKSONVILLE NC
28540-5311
US

V. Phone/Fax

Practice location:
  • Phone: 910-347-2154
  • Fax: 910-347-0728
Mailing address:
  • Phone: 910-347-2154
  • Fax: 910-347-0728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number76450
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number76450
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number76450
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number76450
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number76450
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number76450
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number76450
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code364SP1700X
TaxonomyPerinatal Clinical Nurse Specialist
License Number76450
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: